The National Health Information Infrastructure initiative seeks to improve the effectiveness, efficiency, and overall quality of health and healthcare. Its two goals are to achieve by 2014: (1) widespread adoption of electronic health records (EHRs), to replace paper records in doctors' offices, hospitals, and other care settings; and (2) creation of a National Health Information Network (NHIN). The aim is for EHRs to “interoperate” across the NHIN to allow clinicians to electronically share records with each other, payers, performance monitoring agencies, public health agencies, and consumers.
The U.S. Department of Health and Human Services, the Office of the National Coordinator for Health Information Technology, and the American Health Information Community (AHIC, a federally chartered advisory committee) intend for interoperable EHRs to realize several national healthcare policy goals: to reduce medical errors; to improve overall quality of care; and to produce greater value for healthcare expenditures. In other words, information technology is viewed as key to fixing major problems with U.S. healthcare.
Besides the technologic obstacles, challenges to realizing this vision include how best to use information technology to improve the population's health, patient care, and safety while at the same time protecting patient rights and privacy. Behavioral healthcare has an important role to play in this national discussion.
Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), the mission of the Behavioral Health Standards (BHS) Workgroup is to develop a core of experts and stakeholders on behavioral health standards who can effectively influence national EHR standard-setting processes to address the concerns of behavioral health stakeholders. The BHS Workgroup's most important national policy goal is developing EHR standards for behavioral healthcare providers. Its members include a mix of public and private organizations representing substance abuse prevention and treatment and mental health services, as well as behavioral health software vendors.
One of the BHS Workgroup's first challenges was to become involved with Health Level Seven (HL7). HL7 designs standards and definitions for interoperable EHRs (known as the HL7 EHR System Functional Model) applicable across a wide spectrum of healthcare settings. As the BHS Workgroup formed in 2005, its central purpose emerged: to ensure that the standards being developed not only include data elements critical to behavioral healthcare, but also allow for the exchange of EHRs consistent with federal patient confidentiality and privacy laws.
For example, under federal law any information that might be shared by a substance abuse treatment program requires patient consent, with a limited number of exceptions. Once shared by a program, the information may not be shared or redisclosed by the recipient unless patient consent is obtained again. Since HL7 uses a consensus-based process, the BHS Workgroup is collaborating with other constituencies to develop standards that support patient consent for sharing information.
Through the BHS Workgroup, SAMHSA is providing leadership in developing a behavioral health conformance certification profile, based on the HL7 EHR Functional Model. More than 100 experts are involved in the elaborate, consensus-based process. Once completed, it will be submitted to HL7 as a draft standard subject to a somewhat different HL7 consensus process. If consensus is reached, this profile may be used by organizations such as the Certification Commission for Healthcare Information Technology to certify electronic behavioral health record systems. The profile is expected to be structured so that variants can be derived to support different types of behavioral health providers' and care settings' needs, as well as to accommodate jurisdictions' laws and program requirements.
The BHS Workgroup also has initiated the Behavioral Health Domain Model Project within the HL7 Community Based Collaborative Care Special Interest Group (CBCC SIG). Simply put, the project is developing HL7 standards for messages, services, and documents for sharing behavioral health information. The goal is for the standards to achieve American National Standards Institute (ANSI) accreditation so they may be used in behavioral health EHR applications and reporting systems to support interoperable health information exchange.
In addition, the BHS Workgroup has provided resources and expertise to the CBCC SIG on privacy architecture standards. These standards enable a patient to request that the provider “mask” a procedure, drug, or condition when that information is recorded in an EHR so that only authorized providers or types of providers are able to access this information. Such instructions also may be applied to a subset of the patient's EHR based on the patient's directives. A patient can permit a provider to override masked information, and in an emergency the provider may be able to override the mask without the patient's consent as long as the provider documents acceptable reasons and an audit trail is kept.
The consent standards advanced by the BHS Workgroup originally were developed to support the Canadian Infoway Privacy Architecture, the set of system specifications required to support the exchange of interoperable EHRs in accordance with applicable Canadian privacy laws. They are of interest to the U.S. behavioral health community because they support federal patient consent requirements for limiting disclosures from substance abuse programs. The BHS Workgroup would like to see these specifications considered by the AHIC Confidentiality, Privacy, and Security Workgroup and the ANSI-sponsored Health Information Technology Standards Panel's Privacy and Security Workgroup.